Sec. 1351.007.  LIMITATIONS AND EXCLUSIONS ON COVERAGE PERMITTED.  (a)  A group health benefit plan may include:
(1)  a limitation on the number of visits for home health services for which benefits are payable, subject to Subsection (b);
(2)  an exclusion for home health services coverage for:
(A)  custodial care;
(B)  services provided by an individual who:
(i)  resides in the covered individual's home;  or
(ii)  is a member of the covered individual's family;  or
(C)  services provided to a covered individual who is eligible for Medicare coverage;
(3)  annual deductible and coinsurance provisions for home health services coverage that are not less favorable than the deductible or coinsurance provisions applicable to hospital services coverage under the plan;  and
(4)  other coverage limitations or exclusions consistent with the remaining provisions of the plan.
(b)  A limitation under Subsection (a)(1) may not limit each individual covered under the plan to fewer than 60 visits in any calendar year or continuous 12-month period.
(c)  For purposes of this section, each of the following is considered to be one visit for home health services:
(1)  a visit by a representative of a home health agency;
(2)  four hours of home health aide service;  and
(3)  if home health aide service extends beyond four hours, each additional four hours or portion of that four-hour period.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005.